An Overview of Structural Approaches to HIV Prevention

Introduction

I. Definition of the Prevention Area

A "structural approach" to HIV prevention is the process of selecting a set of interventions that address structural factors to reduce HIV risk at the individual and/or group level. Structural factors are elements outside of individual knowledge or awareness that have the potential to influence the vulnerability of individuals and groups to HIV infection. They can include social (e.g., stigma, gender inequality), legal-political (e.g., laws and regulations), cultural (e.g., religious beliefs), and economic (e.g., lack of livelihood opportunity) factors.

Structural factors fall into two conceptual categories:

"Risk drivers," factors that have been empirically shown to shape patterns of risk behavior in particular populations

"Environmental mediators," which increase people's resilience to HIV (PDF, 1.23 KB) or hinder their ability to avoid HIV in a particular context (e.g., laws that criminalize and drive underground men who have sex with men , limiting their ability to seek HIV prevention services.)

II. Epidemiological Justification for the Prevention Area

There is a growing body of quantitative and qualitative evidence linking structural factors to HIV risk and its proximate determinants (e.g., multiple sexual partnering and lack of condom use). Given the complex and numerous pathways between structural factors and HIV transmission, however, few structural programs have been evaluated for their impact on HIV incidence.

Most of the emerging evidence centers on a few factors, including gender inequality, stigma and discrimination, economic empowerment and livelihood opportunities, education, and alcohol. For each of these factors, there is evidence on the impact of interventions that target them, although the relative importance of particular structural factors varies across settings.

One randomized controlled trial (RCT) that linked structural factors with HIV biomarkers found significantly lower levels of HIV and HSV-2 among Malawian schoolgirls who received monthly cash payments than among those who did not receive the payments. In Kenya, a study showed that reducing the cost of primary education by paying for school uniforms reduced dropout rates, teen marriage, and childbearing--all factors closely related to HIV risk. Other HIV prevention programs have addressed structural factors by changing norms around gender and violence against women, supporting micro-credit programs, and strengthening the legal rights of underserved populations. A recent Journal of the International AIDS Society (JIAS) supplement discusses the necessity of addressing these and other structural factors in future HIV investments. Service models need to be adapted to the economic and social environments of clients, and HIV programming incorporated into wider gender and development efforts.

III. Core Programmatic Components

There is now widespread agreement that structural approaches are a critical part of a "combination HIV prevention" strategy. In addition to the positive outcomes structural interventions can achieve on their own, they are important to the success of biomedical and behavioral interventions. For example, voluntary medical male circumcision provision programs may not realize their potential impact without including activities that address structural factors, such as socio-cultural norms that influence men and women's preferences around circumcision (PDF, 1.18 MB) and mobility-constraining poverty that may limit access of certain populations to services.

There is no "one size fits all" structural approach that is appropriate for all epidemics, settings, or target populations. A defining component of a structural approach to HIV prevention is choosing a set of interventions according to evidence- informed analysis of the particular characteristics of the target population, the context, and of the risk drivers and environmental mediators of HIV in that specific setting. In a setting where, for example, migratory labor is common and laborers are found to have especially high levels of HIV, a structural approach could include workplace HIV prevention (PDF, 444 KB) interventions for migrant laborers or an intervention to create alternative sources of economic opportunity. In an epidemic where HIV is transmitted primarily through sex work, a priority intervention could be engagement of local authorities to enforce condom use in brothels.

Although there is no single structural approach appropriate for all settings, there are a number of key considerations and features characteristic of good structural programming. These should be addressed in the development and implementation of structural approaches in any setting:

clear articulation of the causal pathway between the structural factor and HIV risk and of where along this pathway the intervention aims to have impact

understanding of the intervention's possible unintended effects

definition of the macro (national/regional), meso (community), and/or micro (individual/family) level at which the intervention expects to have influence

These considerations are delineated in the AIDSTAR-One Structural Resource Tool (forthcoming).

IV. Current Status of Implementation Experience

Structural interventions are not new to public health prevention strategies. Well known and successful examples include increasing taxes to reduce or prevent smoking and national programs to put fluoride into drinking water to prevent tooth decay. In the HIV arena, however, the importance of structural interventions has only recently garnered significant attention. There is limited consensus around key concepts, definitions, what works, and the causal pathways through which successful programs create impact. This is in part due to gaps in the evidence base, many of which result from the technical challenges of measuring the impact of structural programming. The position paper series developed by AIDSTAR-One and STRIVE makes progress on some of these issues. It provides definitions for key structural HIV prevention concepts, analysis of the current evidence base and gaps, frameworks for approaching structural prevention, and lessons from field-based implementation experience.

Measuring the effectiveness of structural intervention programs can be difficult for several reasons:

there is no direct, one-to-one relationship between structural interventions and HIV incidence

structural interventions are often not amenable to randomization

causal pathways from intervention to end point outcomes are usually indirect and complex

there has been limited funding to study these questions at a scale proportionate with funding for research on biomedical and behavioral interventions.

Existing evaluations of the effect of structural interventions on HIV and proximal behavioral outcomes use multiple, diverse methodologies to allow triangulation of data. Methodologies include RCTs (PDF, 104 KB), quasi-experimental studies, and qualitative studies (PDF, 377 KB). Retrospective studies of broad national responses to the epidemic have combined sources and methods typically used in public health (e.g., HIV prevalence and incidence modeling, behavioral and demographic health survey data, interview and focus group data, and condom shipment data), with some not commonly used (PDF, 78 KB) (i.e., newspaper reports of behavior change). Limitation to conventional methods, such as RCTs, and basis on independent samples may undercut the development of new and effective HIV prevention approaches. Researchers have articulated the need for further engagement with social science methods and the use of combinations of data (PDF, 835 KB) from different types of evaluations, as well as careful inclusion of less rigorous sources to continue to make progress in generating the evidence base.

According to the findings of this recent randomized controlled trial (RCT) in Malawi, girls and young women aged 13 to 22 who receive regular small cash payments are less than half as likely to acquire HIV than their counterparts who receive no cash payment. The study recruited approximately 1,300 never-married young women living in an area with high poverty, low school enrollment, and high HIV prevalence. The young women and their families were randomized to receive small monthly stipends for 18 months: USD$1 to $5 for the girls and USD$4 to $10 for the families (conditional on school attendance or unconditional), or nothing at all. Girls who received payments were 75 percent less likely to acquire herpes. They were also more likely to attend school, less likely to be having sex regularly, and less likely to have a partner over the age of 25. The authors did not detect a difference in age of sexual debut or condom use, and found no notable difference in HIV and HSV-2 prevalence between the conditional and unconditional cash transfer groups. According to the authors, simple cash transfer programs for unmarried schoolgirls and their families may have a significant impact on their sexual and reproductive health. They encourage policymakers to consider such programs as one component of combination prevention approaches.

This article discusses a series of papers published in a recent supplement of the Journal of the International AIDS Society highlighting some of the social, economic, political, and environmental structural factors that increase susceptibility to HIV infection and undermine current prevention and treatment interventions. According to the authors, future investments in combination prevention and broader gender and development initiatives must include structural factors to ensure both clinical efficacy and effectiveness at a population level. They cite the recent trial of a cash transfer intervention in Malawi that showed that providing a small stipend to girls and their households had a significant impact on prevalence of HIV and herpes simplex virus within this population. The papers they cite address a range of issues: how structural interventions may alter social arrangements and often include value judgments; how to change behavioral dynamics among young people and address the prevention needs of the most disadvantaged youths; why inequalities in gender, power, and income lead to increased risk among women's and men's access to care and support services; and how to increase gender equality and livelihood security with effective combinations of structural interventions. The authors stress that future investments are needed to define the political and programmatic impact of structural interventions on reducing HIV incidence.

This study analyzes two structural drivers of HIV for young people: gender inequalities and livelihood insecurity. The authors identified nine structural interventions focusing on gender microfinance and gender empowerment, girls' education, and gender empowerment and financial literacy targeting young people. Across all nine interventions, the authors identified three lessons learned: 1) interventions have a narrow conceptualization of livelihoods, 2) there is limited involvement of men and boys in such interventions, and 3) few studies have been done in real-world contexts. According to the authors, the interventions focused on building human and financial capital, and neglected to consider other forms of capital, systems, or institutions that often supplement and influence livelihood programs, including educational systems and state policies. The authors support including men and boys in combined interventions, but caution that further research is necessary to ensure that their participation adds value rather than detracts from the work of gender equality. They stress that successful interventions primarily carried out in rural or educational contexts must be adapted to more urban settings and to a variety of contexts.

Addressing Social Drivers of HIV/AIDS for the Long Term Response: Conceptual and Methodological Considerations

Auerbach, J.D., J.O. Parkhurst, and C.F. Cáceres. 2011. Global Public Health: An International Journal for Research and Practice. Vol 6, Supplement 3.

This paper provides a framework and guidance on the social and structural drivers of the HIV epidemic to move the HIV prevention field forward. There is a paucity of concrete definitions for social and structural constructs and the authors discuss some of the important terms used throughout the social science discourse. They also outline the various hypotheses and causal pathways in the social science field, and provide a logical framework for how to address the social/structural drivers through interventions. The operational structure that is provided goes through six steps: 1) identify the target populations and/or locations for intervention, 2) identify the key behavioral patterns and drivers of behavioral patterns for the target population, 3) chose level of structural intervention, 4) describe planned and potential changes and outcomes, 5) design the intervention, 6) implement, monitor, evaluate, and feedback. The authors conclude that HIV and AIDS experts should support the incorporation of social and structural approaches in the global response to improve positive health outcomes in the future. Much more work, however, also needs to be accomplished through the implementation and evaluation of programs.

This randomized experimental study conducted in Kenya found a possible causal link between school attendance and reduced HIV risk factors. Three school-based HIV and AIDS programs were implemented: 1) training teachers in the Kenyan Government's HIV and AIDS education curriculum, 2) facilitating student debates on the role of condoms and having them write essays on how to prevent themselves from acquiring HIV, and 3) decreasing the cost of education. The authors collected measures of knowledge, attitudes, and behavior related to HIV. The study's primary outcome measure of effectiveness of the interventions was teenage childbearing, which is associated with unprotected sex. After two years, the study showed that reducing the cost of education by paying for school uniforms reduced dropout rates, teen marriage, and childbearing.

The authors comment on the findings of a cluster randomized controlled trial of a cash transfer program for schoolgirls in Zomba, Malawi, which showed that schoolgirls who received monthly cash payments were significantly less likely than girls who did not receive payments to be infected with HIV and HSV-2, have an older male partner, and have sexual intercourse once per week at follow-up (Baird 2012). The study compared the impacts of providing cash transfers conditional on school attendance, providing cash transfers unconditionally, and providing no cash transfers. In this commentary, the authors discuss the importance of the study in providing evidence that an intervention to change the structural environment through provision of cash payments can impact young women's HIV risk. They also cited the study's limitations, including the fact that HIV incidence was not used as an outcome measure and that few HIV infections were detected. The study was not powered to detect different effects on biological outcomes between the conditional cash transfer and unconditional cash transfer interventions. More research is needed to understand the casual pathways through which the program achieved impact.

"Magic bullet thinking"--that is, prioritizing only the well-defined and measurable biomedical interventions--may inhibit understanding of what works in HIV prevention by leaving out the less easily measurable social and contextual approaches. According to the authors, measuring the impact of combination prevention remains an elusive goal for the HIV prevention community due to the methodological challenges of applying the gold standard of randomized controlled trials for prevention programming. The authors contend that the use of costly randomized designs with the community as unit of intervention may not produce valid data. This is due to a number of challenges in measuring change in HIV incidence, including a lack of reliable, easy-to-use tools to measure HIV incidence at a population level, the need for unrealistically large sample sizes, and the unreliability of intermediate indicators, such as reported behavior change. Plausibility designs--which do not include randomly selected control groups but instead triangulate data sources--may provide important evidence of impact and help explain program effectiveness. The authors encourage the use of a clear description of program components and their potential causal pathways, intermediate outputs, and outcomes leading to HIV incidence reduction. They also encourage the use of mixed methods and modeling as an alternative to probability evidence.

Over the past decade, there have been increasing numbers of successful, practical interventions that address HIV's structural factors, from policy measures that remove user fees for schools in Africa, to sex worker peer-prevention programs in India, to economic safety nets such as cash transfers to adolescent girls in Malawi. This paper examines the relatively recent evidence to produce insights that can strengthen the global response to HIV. The paper profiles: 1) efforts that address structural factors and measure effects on HIV-related behavioral and biological outcomes and 2) interventions that have been demonstrated to affect known HIV-related structural factors, whether or not clinical or behavioral endpoints were assessed, to stimulate thinking on the importance of cross-sectoral approaches. The authors identify several lessons: 1) action on structural factors is a necessary component of the global HIV response, even in the context of the re-medicalization of HIV prevention, 2) action on structural factors is possible, can be highly effective, and is likely context-specific, 3) action on structural factors can benefit other health, development, and human rights objectives in addition to HIV, 4) a range of disciplinary perspectives outside the health sector will be required to implement structural approaches, and 5) cross-sector governance and financing are critical for structural approaches to work.

Today's HIV prevention, care, and treatment strategies are based largely on the science and insights of biomedicine and epidemiology, two disciplines that have traditionally emphasized biological interventions and individual behavior change over measures addressing social or structural sources of risk. Most research has focused on the biological co-factors that affect transmission dynamics, such as the presence of concomitant sexually transmitted infections or the use of prevention methods that reduce transmission likelihood. However, non-biological factors that influence behavior and the likelihood of transmission--such as alcohol use, internalized stigma, economic and consumer pressures that encourage transactional sex, exposure to violence, or the impact of gender norms--also affect HIV transmission. They operate earlier in the causal chain through more varied and complex pathways. Increasingly, scientists and policymakers have begun calling for more attention to the structural forces that create environments of risk, arguing that the touchstone of future programming must be "combination prevention." This paper examines some of the evidence linking structural factors to HIV risk, as well as the research gaps, including the pathways through which factors interact and affect HIV vulnerability. It explores the advantages of taking a "structurally informed" approach to HIV planning and implementation, namely, the value of influencing clustered risk factors, the potential to influence multiple outcomes, and opportunities for co-financing.

The number of government-funded HIV and AIDS services in India's Karnataka state has increased greatly from 2006 to 2010. However, only a minority of key populations access these services. A qualitative study was conducted to understand the barriers to accessing HIV and AIDS care, treatment, and support services. The authors conducted 26 focus group discussions (FGD) with a total of 302 individuals in March and April 2008. Participants include female sex workers, men who have sex with men, and transgendered individuals. They found that participants were knowledgeable about how HIV was transmitted and acquired, and were accurate in measuring their own risk level. There was a large degree of fear surrounding an HIV-positive test result. There was also little knowledge about care, support, and treatment services, which hindered them getting tested. A motivator to getting tested, however, was wanting to live a longer and healthier life. Stigma and discrimination from family, friends, and healthcare providers were barriers to accessing HIV and AIDS services, as were fears of breaches of confidentiality. Additional structural barriers to using services included long travel distances, cost for "free" services, and needing an ID card that they did not have. Much needs to be accomplished in terms of educating communities and health workers to reduce the stigma and discrimination reported in the study. The authors recommend that HIV testing services should be integrated into existing clinics for female sex workers and men who have sex with men and trans populations to increase their HIV status knowledge as well as improving the quality of government services.

This systematic review of 16 studies using cash for prevention of sexual transmission of HIV found that the majority of cash transfer programs have targeted adolescents and address such structural risk factors as poverty. According to the authors, cash transfer programs--both unconditional and conditional, which are tied to behaviors deemed beneficial to the individual--are reaching over 1 billion people in developing countries. The majority of studies on these programs have found positive impacts on sexual behaviors, although, due to a lack of biological endpoints in data collection, only one study has been able to make a direct correlation between a decrease in HIV prevalence and cash payments. According to the authors, cash programs either address upstream drivers of risk, such as poverty and education, or downstream behavior change, such as receiving cash for negative results on a test for a sexually transmitted infection. The authors caution that the downstream approach may have unintended consequences, such as violence or coercion, although they also note that to date there is no evidence of social harm to individuals participating in cash transfer programs. The authors note that the amount of payment will likely affect results and that clear and transparent selection criteria are critical. They encourage the use of formative and ethnographic research and pilot studies to determine the most effective structure for cash transfers to reduce risk. The authors hypothesize that cash transfer interventions may also be used to encourage HIV testing, HIV-related health visits, and adherence to antiretroviral drugs. A presentation at the 2012 International AIDS Conference provided evidence that cash transfers helped increase birth registration and school attendance in eastern Zimbabwe.

Fifty in-depth interviews were conducted to gain perspectives on how property rights influence primary and secondary HIV transmission. Participants were recruited through a community-led land and property rights development project in rural Kenya, where HIV prevalence is high and property right violations are prevalent. Interview themes consisted of questions on what happened to women when their husbands died, the reasons for property rights violations, and the perceived links between property rights violations and HIV transmission. Outside interviewers unknown to the participants conducted the interviews in the local language, for about 1.25 to 2.25 hours. They found that women would often "disappear" shortly after their husband died. Oftentimes, the husband's family blamed the wife for giving HIV to their son/brother so felt that she did not deserve the property or assets. The interviewees clearly saw the link between property rights violations and increasing HIV prevalence rates in the community. Women left their homes in search of shelter, food, and a livelihood. If she were HIV-positive, this made the continuation of care and treatment almost impossible. If she were HIV-negative, she would be vulnerable to infection from partners whom she would not otherwise have had if she were able to keep her property. The authors conclude that securing women's property rights could decrease her, and the community's, vulnerability to HIV infection and transmission.

Studying how food insecurity contributes to increased HIV risk among 12,684 sexually active Brazilian women, the authors conclude that severe food insecurity with hunger is associated with lower levels of condom use. Using a multi-variable logistic regression model, the study examined the associations between food insecurity, condom use, and symptoms of sexually transmitted infection. The research revealed that severe food insecurity with hunger is associated with statistically significant reduced odds of consistent condom use and condom use at last sexual intercourse, and with self-reported itchy vaginal discharge, most likely indicating the presence of a sexually transmitted infection. The study employed a culturally adapted 18-item food insecurity scale measuring a wide range of human experience with food insecurity, from food security to severe food insecurity with hunger. According to the authors, the findings add to the abundance of new data that highlight the importance of food insecurity in relation to women's risk of sexual violence and exposure to HIV. They recommend that HIV prevention programs target high-risk women through food supplementation or livelihood interventions to help equalize gender-based bargaining power within households. They stress that to be consistently effective in reducing HIV risk, biomedical, individual-level cognitive, and behavioral interventions for HIV prevention must also address structural factors, such as food insecurity.

The review presents the evidence base for HIV and sexually transmitted infection (STI) prevention interventions among female sex workers in resource-poor settings. The review only included randomized controlled trials or studies that included a control group. The authors identified 1,272 articles and abstracts across the various databases, and 28 of these met the selection criteria. Twenty-five interventions were focused at the individual level and three targeted structural interventions. Half of the studies evaluated a combination of behavioral interventions and STI treatment, seven studies focused on increasing condom use, four evaluated a vaginal microbicide, and three evaluated structural interventions. Almost all of the studies (93 percent) reported on changes of STI/HIV incidence or prevalence. Those with positive findings included interventions that focused either on a combination of behavioral interventions and STI treatment or on increasing condom use. There was either no effect or an increased risk of HIV in the microbicide studies. The three structural interventions were highly successful. The authors discuss the limitations of the review and recommend next steps for future evaluations.

The Tap and Reposition Youth (TRY) Program was implemented by the Population Council and K-Rep Development Agency, a microfinance organization, in low-income areas in Nairobi, Kenya from 1998 to 2004. The program targeted out-of-school females aged 16 to 22 years old. The goal of the program was to reduce female adolescent's vulnerability to negative social and reproductive health outcomes by involving them in a microfinance project. The project went through three stages. The first phase organized a group of 25 young women, who were trained, contributed to a group savings plan, and were offered microloans to start small businesses. Participation was high in the beginning of phase one, but the young women eventually started dropping out of the program. Based on lessons learned from the first phase, the second phase strengthened the social components to provide more support to the young women. However, it was found that they continued to exit the program because they were concerned for the safely of their savings, since members defaulted on their loans, or needed it for emergencies. The third phase offered women access to safe and secure savings as well as the necessary social support, but did not have the loan and repayment portion of the original program. It was found that the initial program's focus on loans and repayments was only successful for the most stable and least vulnerable young women. Social support interventions and safe loans were more immediate needs for the majority of women in this setting. The authors suggest having different types of economic development interventions based on the level of stability and vulnerability of the young women targeted for the project.

According to the authors, structural approaches that address social, economic, and political factors beyond the control of individuals are still lacking in both the global and national responses to HIV. This synthesis paper outlines six key recommendations and provides specific guidance from the Social Drivers Working Group of the aids2031 initiative. These actions are designed to operationalize structural approaches that will increase uptake and sustainability of behavioral and biomedical prevention approaches. The authors argue that addressing the root causes of vulnerability, such as gender inequity, may have the greatest effect in reducing vulnerability to HIV. The six actions identified by the working group include:

• Integration of HIV efforts with broader health and develoliment should be suliliorted through inter-sectoral AIDS coalitions.

• Governments and donors should invest in sociological assessments to identify the social context as liart of routine efforts to "know your eliidemic."

• Civil society and affected communities--including women living with HIV, networks of affected liersons, and young lieolile--must be fully engaged in lilanning and liriority-setting activities.

• Substantial and long-term structural aliliroaches should be funded for liroject cycles of 5 to 15 years or more.

• Monitoring and evaluation frameworks must account for multidimensional changes in the social, economic, and liolitical environments.

• Laws that reduce stigma and lirotect human rights and equity must be effectively imlilemented and monitored.

• Integration of HIV efforts with broader health and develoliment should be suliliorted through inter-sectoral AIDS coalitions.

Sex work is a major route of HIV transmission in many Asian countries and effective interventions that address the HIV risk of sex workers and their clients are greatly needed. This paper describes the 100% Condom Use Programme, which was conceived in 1989 and has been implemented in Thailand, Cambodia, Philippines, Vietnam, China, Myanmar, Mongolia, and Laos PDR. It achieved success in many cases. In each country, program components have been adapted to fit the local context. However, the program universally aims to empower sex workers to refuse sex without a condom. Key strategies applied in all contexts have been to promote "No condom - No sex" in all types of sex work and collaboration among local authorities, sex business owners, and sex workers. In some contexts, program components include formation of sex workers' self-help groups, peer education, and issuance of membership cards by local authorities. The nationally-implemented 100% Condom Use Programmes in Thailand and Cambodia have been credited as the main factor contributing to the decline in those countries' HIV epidemics.

This report describes a quasi-experimental evaluation of Programa H, a program implemented in Brazil to change young men's attitudes towards traditional gender roles and sexual relations and to reduce HIV risk behaviors and intimate partner violence. The evaluation used a survey and qualitative interviews to compare different combinations of the program components. Components included interactive group education sessions for young men led by adult male facilitators and a community-wide "lifestyle" social marketing campaign to promote condom use, using gender-equitable messages that echoed those used in the group education sessions. The researchers developed and used the Gender-Equitable Men (GEM) Scale to measure attitudes toward gender norms related to such topics as HIV prevention, intimate partner violence, and sexual relationships. Evaluation results showed significant behavioral and biological changes among 15- to 25-year-olds at intervention sites, including an increase in condom use with primary partners and reduction in reported sexually transmitted infections (STI) symptoms. Further, young men's decreased support for inequitable gender norms over one year was significantly associated with decreased reports of STI symptoms.

This study combined analysis of several different types of evidence--some traditionally used in public health and some not--to identify the changes in sexual behavior that led to the marked reduction in the prevalence of HIV in Uganda in the early 1990s. Seven types of evidence were used, including models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda; reports of behavior change in the primary newspaper in Uganda; surveys with questions about perceptions of personal behavior change; large demographic and health surveys and large Global Program on AIDS surveys with questions about sexual behavior; smaller surveys of reported sexual behavior; reports of numbers of condoms shipped to Uganda; and historical documentation of the implementation of HIV prevention programs in Uganda. The study found consistency among the findings from the different types of evidence examined, concluding that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships and subsequently increased condom use with non-marital and non-cohabiting partners.

The lessons of the past 30 years of the response to the HIV epidemic have pointed to three key objectives that future behaviour change based HIV prevention efforts must work to achieve: 1) address broader structures shaping behavioral risk and vulnerability, 2) tailor responses to the factors influencing risk and vulnerability understood to affect the target population, and 3) ensure multiple factors can be addressed when needed. This paper provides definitions of key terms and concepts that may help in the operationalization of an approach that meets these objectives. A "structural approach" is defined as process undertaken to decide upon an appropriate set of structural HIV prevention interventions. It is a "process" because it is impossible to define in advance what activities to undertake, "appropriate" because HIV prevention must be tailored to local realities, and a "set" of activities because risk is typically shaped by multiple factors. Structural factors can be broad, encompassing the multitude of potential elements that might shape risk and vulnerability for different populations. Structural drivers encompass an identified set of factors empirically shown to influence risk for a given target group. Other key operational terms (e.g., causal pathways, levels of influence) and additional considerations, such as unforeseen and undesirable consequences to changing structural factors, are discussed.

"Structural factors" are characteristics of the social, economic, legal, and cultural environment that act as determinants of HIV risk for whole populations and influence how this risk is distributed within populations. To date, "structural approaches" that engage these factors remain poorly developed. HIV-prevention programmers deploy limited resources over set timeframes with the primary goal of reducing HIV infection rates and disparities. They do not themselves set broad social policy or research agendas, but both respond and seek to influence these. They are often motivated to adopt a structural approach within combination HIV prevention. This paper proposes a three-pronged structural approach to be used by HIV-prevention programmers: 1) social epidemiology targeting to enhance equity of HIV prevention, 2) interrupting the causal pathway from social determinants to risk through critical enabler interventions, and 3) addressing structural factors directly through HIV-sensitive, cross-sectoral development. This approach can be tailored to populations, considers factors beyond provision of information alone, and recognizes that multiple factors shape risk patterns. It overlaps with the investment framework proposed by UNAIDS in 2011, which proposes three categories of investment required for a comprehensive response: basic programmatic activities, addressing critical enablers, and achieving development synergies. The author describes how a structural approach can inform action in all three categories.

The evidence of the effectiveness of structural interventions for HIV prevention is lacking in comparison to the evidence for interventions in other prevention areas, despite the key role of structural interventions in combination prevention approaches. This role is recognized in global guidance. While "structural prevention" has received significant attention in the academic community in recent years, the challenges to program implementation at the community and national levels are not well understood. This paper discusses the experience of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR)/U.S. Agency for International Development (USAID) in implementing structural interventions in Zambia. The authors propose several ways to expedite the implementation process.

A systematic review of late phase randomized controlled trials (RCTs) for prevention of sexual transmission of HIV found that only six, all evaluating biomedical interventions, demonstrated definitive effects on HIV (five reduced transmission; one had adverse effects). The authors conducted a review of RCTs for prevention of sexual transmission, identifying 37 trials (reporting on 39 interventions) from over the last 30 years. Three male circumcision trials, one trial of sexually transmitted infection treatment and care, and one vaccine trial significantly reduced HIV. One microbicide trial of nonoxynol-9 gel produced adverse results. The authors cite problems in design and implementation that impeded the studies. According to the authors, while well-designed and executed RCTs should remain the gold standard in defining the evidence base for prevention programs, public health researchers and practitioners must also employ complementary lines of evidence and observational studies. The HIV prevention science community must also examine trials that failed to demonstrate results to learn how to improve study design and implementation.

The literature review explores the linkages among poverty, livelihood, food security, economic strengthening, and HIV- and AIDS-related outcomes. It found that the linkages between poverty and HIV and AIDS were mostly based on qualitative research, and had an unclear link. Quantitatively, there were conflicting results between poverty and HIV and AIDS. The literature is stronger in providing links between food insecurity and HIV and AIDS outcomes, with food security positively impacting antiretroviral adherence and mortality. There were relatively few studies exploring the link between economic strengthening and HIV and AIDS outcomes. While most studies were qualitative, they generally agreed that improved economic standing improved HIV and AIDS outcomes. The authors conclude that there is strong evidence linking food insecurity, hunger, and the needing to earn money to accessing and utilizing HIV and AIDS care, treatment, and support services.

Integrating Gender into HIV/AIDS Programmes in the Health Sector: Tool to Improve Responsiveness to Women's Needs

WHO. 2009.

The tool was developed for program managers and providers who develop, implement, manage, or evaluate HIV and AIDS programs. It enables them to increase awareness on how gender can affect an individual's access to and experience with HIV and AIDS programs and services. The tool provides guidance on how to develop or modify a program to make it more gender-friendly. Four HIV or AIDS services are specifically identified and details are provided on how to address key gender issues. These services include: HIV testing and counseling, prevention of mother-to-child transmission, and HIV and AIDS care and support. The tool was field tested in five countries and can be used in a number of different settings, such as trainings, development of curricula, and the integration of gender issues in strategies.

The Men As Partners Program works to address the imbalance between reproductive health programs focusing on women and the degree of decision-making power that women often have about their health-seeking behaviors. As such, the program focuses on educating men about the importance of good reproductive health--both their partner's and their own. The program also works to increase men's access to reproductive health services and catalyze men to "take an active stand for gender equity and against gender-based violence." This website contains technical publications related to the Men As Partners program, including a program manual and men's reproductive health curriculum, as well as multimedia resources.